Patient Feedback Form

We at Associates in Family Medicine are committed to providing quality and complete care to our patients. This includes protecting your privacy as a patient and listening when things aren’t going the way they’re designed. We will do our best to address any concerns from our patients, with the hope of bettering our practice and the care we provide.

Please feel free to use the form below to send us your feedback, or you are welcome to call the office and ask to speak to an administrator.



[contact-form to=’’ subject=’AFM Website Patient Feedback’][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Date of Birth’ type=’text’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Phone Number’ type=’text’ required=’1’/][contact-field label=’Full Address’ type=’text’/][contact-field label=’Today%26#039;s Date’ type=’text’ required=’1’/][contact-field label=’NATURE OF YOUR CONCERN OR COMPLIMENT’ type=’select’ required=’1′ options=’,Billing,Customer Service,HIPAA,Quality of Care,Other’/][contact-field label=’If OTHER, please categorize.’ type=’text’/][contact-field label=’DETAILS: Please be as specific as possible and include the following – (1) please state your concern/compliment, (2) date and time of event, (3) location of event, (4) staff member(s) involved.’ type=’textarea’ required=’1’/][/contact-form]